Have you ever had an agency (insurer or intermediary) cancelled or refused?*

Are any insurance activities outsourced to third parties? If so, please provide full details.*

Do you have any Sub-Agents or third parties who introduce business to you in respect of the classes of business to which this application relates?*

In respect of general insurance, are you currently, or do you intend to be, acting as an appointed agent, appointed sub-agent or introducer for any other insurer or intermediary? If so, please provide full details of such arrangements.*

Are you authorised by the FCA?*

Yes

No

If yes state Authorisation Number

If ‘NO’ do you intend to become authorised? (Please state intentions)

Please complete the following questions with regards to either the Proprietor or Managing Director responsible for the Firm.

Name*

Home Address*

Contact Number*

Date of Birth*

National Insurance Number or Passport Number (only required for Sole Traders)*

Business Title*

Professional Qualifications*

Criminal Convictions (past or pending)*

Have you or any of your personnel actively involved in general insurance activities:

Have you or any of your personnel actively involved in general insurance activities:*

Yes

No

Ever been adjudged by a court liable for fraud, misfeasance, wrongful trading or other misconduct?*

Yes

No

Ever knowingly been the subject of an investigation into misconduct or malpractice?*

Yes

No

Ever been declared bankrupt?*

Yes

No

Ever been disqualified from holding a directorship?*

Yes

No

Ever had a petition for the compulsory winding up of a business served in the last ten years?*

Yes

No

Ever been subject to a disciplinary proceeding by any professional body e.g. C.I.I., I.B.R.C., etc.*

Yes

No

Ever had a receiver, administrative receiver, or administrator appointed, been placed into liquidation, been dissolved, had estate sequestered or failed to satisfy a debt judgement in the last ten years?*

Yes

No

Declaration*

I/we hereby apply for agency facilities with HFIS plc and confirm that the above information is accurate and truthful. I/We understand that once I have been supplied with the HFIS Terms of Business Agreement, and this has been signed, I will be bound by this and undertake to abide by the terms set out therein.

I/we also understand that the relationship will be on an introducer basis which means that I will not provide any advice or recommendations to clients or potential clients on the matter of general insurance or general insurance contracts.

I/we also agree to HFIS carrying out a Credit Search if required. I understand this will be carried out by Experian and may include updates at random intervals.

By submitting this form I agree to the above declaration’ and the declaration will be shown in full